Response to EC Consultation Green Paper – Towards a Europe free from tobacco smoke: policy options at EU level
31 May 2007
European Federation of Allergy and Airways Diseases Patients' Associations(EFA)
Susanna Palkonen and Mariann Skar
35 Rue du Congrès, 1000 Brussels
Tel. +32 (0)2 227 2712
Fax. +32 (0)2 218 3141
Email ,
www.efanet.org
International Primary Care Respiratory Group (IPCRG)
Siân Williams
Department of General Practice and Primary Care
Fosterhill Health Centre
Westburn Road, Aberdeen
Scotland AB25 2AY, United Kingdom
www.theipcrg.org
Introduction
European Federation of Allergy and Airways Diseases patients’ Associations[1] (EFA) and International Primary Care Respiratory Group (IPCRG)[2] welcome the Green Paper – ‘Towards a Europe free from tobacco smoke: policy options at EU level’ and the opportunity to response to the consultation.
The following EFA members contributed to the development of this response: Allergy and Asthma Federation, Finland, the Pulmonary Association Heli, Finland, Asthma UK, Norwegian Heart and Lung Association, Lithuanian Council of Asthma Clubs, Hjärt- och Lungsjukas Riksforbund, Sweden, Dutch Food Allergy Organisation, Associazione Italiana Pazienti BPCO, and Astma-Allergi Forbundet, Denmark.
EFA and IPCRG wish to congratulate the European Commission for its well-researched description of the problem and consequences. In particular we welcome the fact that all relevant issues are covered and all sections are well documented, researched and discussed.
EFA and IPCRG submit the following comments for consideration:
1. Which of the two approaches suggested in Section IV would be more desirable in terms of its scope for smoke-free initiative: a total ban on smoking in all enclosed public spaces and workplaces or a ban with exemptions granted to selected categories of venues?
EFA and IPCRG find a total ban the only effective option available in protecting all EU citizens from harm caused by involuntary exposure to second hand smoke (SHS), which is a proven and classified carcinogen, causes a great deal of respiratory disease – and is a major source of nuisance and exacerbation for people with asthma, allergic illnesses, chronic obstructive pulmonary disease (COPD) and other chronic disease leading to social and work exclusion and unnecessary illness.
For some of these diseases it also stops their most important treatment from being effective. In addition, vulnerable groups and especially children need protection. Several studies have shown the link between second hand smoke and diseases[3].
Partial bans particularly in the hospitality sector, do not work and lead to confusion and non-compliance. Everybody deserves the same level of protection. Extending protection from a known carcinogen to some workers, but excluding others, cannot be justified under any existing principles of occupational health and safety. This is particularly the case with workers in the hospitality sector – who are exposed to some of the highest levels of passive smoking and toxins – and are most likely to be denied the protection conferred by workplace smoking bans if exemptions are granted.
Partial bans are economically unfair because they can lead to an uneven playing field. If employers are given the choice as in Spain, where bars and restaurants under 100 metres sq have the right to remain smoking or to become non-smoking, less than 10% of establishments became non-smoking after the imposition of the Spanish smoke-free law on 1 January 2006[4].
The goal of a total ban is to protect everybody (including hospitality sector, technical and cleaning personnel) from second hand smoking. It is also a signal for children and adolescents that smoking is an addiction and that it is socially unacceptable.
2. Which of the policy options described in Section V would be the most desirable and appropriate for promoting smoke-free environments? What form of EU intervention do you consider necessary to achieve the smoke-free objective?
Binding legislation
EFA and IPCRG believe that the EU not only has a mandate, but the responsibility to introduce binding legislation to put an end to exposure to SHS for all, no matter where they live in the EU, and thus help to protect their right to breathe healthy indoor air as recognised by WHO[5]. In fact, the recent Pan European EFA survey ‘Fighting for Breath’ for people with severe asthma found that one of their major wishes for the future was to be able to breathe healthy air; indoors and out[6].
Binding legislation either based on existing directives or separate directives is also the most cost-effective means for all concerned. Now is the right time to make a positive difference in the daily life of EU citizens.
There is no doubt that SHS constitutes a severe health hazard. Yet to date this hazard has been recognized by the governing institutions of the Community only in an indirect way. What is urgently needed, now, is the official recognition by the Community that SHS is a cause of severe disease and death in order to enable the inclusion of SHS into the hazards under regulation by directive 89/654/EEC.
The Commission has a general mandate to assure a high level of safety and health in the workplace and a specific mandate to regulate smoking at work. Also, by ratifying FCTC, the Commission has made a firm commitment for the protection from tobacco smoke in indoor workplaces. Under these conditions, two major steps forward to approach smoke free workplace legislation in the EU could be;
o the official recognition of SHS as a serious health hazard and
o the appropriate amendment of a Directive on occupational safety and health, could have a good chance to succeed.
Although the legislative process may take some time, the EFA and IPCRG agree that our aspiration must be for an enforceable smoke free Europe. We are committed to support in raising the necessary support for this in the EU, as well as in the national level through our membership.
EFA and IPCRG recognise that binding legislation require acceptance by the general population, in order to be effective. Many countries have already provided evidence for this policy to be viable and enforceable. The latest Eurobarometer reveals that an overwhelming majority of 88% support smoke-free offices, indoor workplaces and public spaces. A majority of Europeans are also in favour of smoke-free bars (62%) and restaurants (77%). Support for smoke-free policies is highest among citizens in countries where such policies have already been introduced, such as Ireland, Sweden and Italy.
EFA and IPCRG want to underline the need for consideration on effective enforcement and for a proper preparation and campaigning process prior to the introduction of new legislation. Experience from Ireland, Norway and other places suggests that prior information campaigns and high levels of public acceptance ensure almost full compliance at little or no extra cost to governments. Attention should also be paid to the need to have a well-funded and effective smoking cessation framework in place at Member State/sub national level, as appropriate, before the introduction of comprehensive legislation. Data from Ireland and Scotland indicate that most quit attempts took place before the legislation came into force. Such provision would then maximise the public health benefits of this legislation for smokers as well as non-smokers.
However, no Member States should wait for the EU regulations, but as quickly as possible start a process of implementing smoke-free environments.
No change from the status quo
EFA and IPCRG find the status quo is not an option, given the risks to health from second hand smoking.
Voluntary measures
Long experience and hard evidence has proven that voluntary measures do not protect workers and members of the public form the exposure to second hand tobacco smoke.
Open method of coordination
EFA and IPCRG appreciate the benefits that the Open method of coordination may bring, but remain convinced that a voluntary approach is not capable of introducing smoke free enclosed public and workplaces everywhere across the EU. However, we will welcome and encourage Member States to share their experiences.
Commission or Council Recommendation
A Council Resolution of 1989[7] and a Council Recommendation 2003/54/EC[8] already exist and have called on Member States to provide protection from exposure to environmental tobacco smoke in indoor workplaces, enclosed public places, and public transport. Yet according to the latest Eurobarometer, one in three Europeans working in indoor workplaces still declare to be exposed to tobacco smoke at work.
3. Are there any further quantitative or qualitative data on the health, social or economic impact of smoke-free policies, which should be taken into account?
The EFA and IPCRG find that the scientific data is well researched and adequate.
The problem of second hand smoke is of major interest to both organisations and we wish draw attention to the following additional data:
Support for smoke-free policies
In 2004 when Norway introduced smoke free workplaces only 54% of the population was positive to this. In 2006 the percentage is 78%! From 2003 to 2006 the percentage of smokers in the population has gone from 27 % to 24%, another positive result.
In Lithuania 60,6% of respondents in a recent survey are positive to the ban of smoking and 15,6% of the respondents admit that they now smoke less.
Chronic Obstructive Pulmonary Disease (COPD)
According to WHO’s Global Burden of Disease Study 2004 tobacco, high blood pressure and alcohol are the most common cause for early death. Tobacco smoke is the largest risk factor for developing COPD in the developed countries. COPD is a leading cause of morbidity and mortality in the world. It is the fourth leading cause of death in Europe and in the USA. The impact of COPD has grown immensely during the last 20 years, especially among women. Previously, most COPD-patients were men, but in recent years the prevalence among women has increased and in the Nordic countries there is hardly any difference in COPD prevalence between men and women[9].
Asthma
Exposure to second-hand smoke at work doubles the risk of adult-onset asthma[10] and children whose parents smoke are 1.5 times more likely to develop asthma[11]. Exposure to cigarette smoke has also been shown to reduce the effectiveness of some important asthma medications[12].
In the UK, one in five people say they feel excluded from parts of their workplace where other people smoke, 40% of adults with asthma say they avoid smoky pubs and restaurants, 36 per cent of people in England cite a smoke-filled atmosphere as the main turn-off for going to a bar or pub[13] and 82% of people with asthma say that second-hand smoke makes their asthma worse.[14]
Over two thirds (67 per cent) of people in England would rather spend the evening in a smoke-free venue, than one where smoking is allowed, 71 per cent of regular pub-goers support the legislation in England, as well as 76 per cent of the overall population, and 87% of non-smokers and 76 per cent of the population believe that going smoke-free will have a positive effect on health[15]
Allergy
Research shows that smoking and exposure to second hand smoke is a major factor in provoking allergic responses by babies and young children[16] [17].
4. Do you have any other comments or suggestions on the Green Paper?
One thing to consider is that the cigarette in a way has become a part of our culture in the sense that it is a product you can buy today, but if introduced now, it wouldn’t be allowed at all. That in itself is a rather peculiar message we are sending. People could get the impression that the cigarette somewhere after all has been approved.
Thank you for this welcome opportunity to contribute to this consultation. Our response is based on consultation with EFA members and the IPCRG internal consultations processes.
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2
EFA-IPCRG response to the Commission Green Paper Consultation Towards a Smoke free Europe
[1] EFA is a non-profit network of allergy, asthma and chronic obstructive pulmonary disease (COPD) patient organisations committed to improve the health, participation and quality of care of patients with these diseases and prevention in Europe.
[2] The IPCRG is a charitable organisation committed to improving respiratory care in primary care on a European and worldwide scale.
[3] Infant death (Anderson and Cook, 1997), Asthma and children (Chilmonczyk, Salmun et al., 1993;Strachan and Cook, 1998), pneumonia (Cook and Strachan, 1999), ear infections (Bennett and Haggard, 1998), coughing (DiFranza, Aligne, and Weitzman, 2004), breathing problems (DiFranza, Aligne, and Weitzman, 2004), bronchitis (Chan-Yeung and Dimich-Ward, 2003).
Other studies suspect that children exposed to smoking have a greater risk for: colick (Sondergaard, Henriksen et al., 2001), reduced intellectual capacity (Yolton, Dietrich, Auinger, Lanphear, and Hornung, 2005), cavaties (Aligne, Moss, Auinger, and Weitzman, 2003), cancer in childhood e.g. leukemi and brain cancer (Sorahan, Prior et al., 1997), cancer in the lungs (Vineis, Airoldi et al., 2005), breast cancer (Lash and Aschengrau, 1999), longterm illness (Eriksen, 2004), Diabetes (Weitzman, Cook et al., 2005).
[4] Press release from the Ministry of Health, Madrid 2 February 2006.
[5] World Health Organization. The right to healthy indoor air. Report of a WHO meeting, Copenhagen, Denmark, 2000. URL http://www.euro.who.int/air/activities/20030528_9.
[6] Dockrell M, Partridge MR, Valovirta E. The limitations of severe asthma: the results of a European survey. Allergy 2007;62:134-141. http://www.efanet.org/activities/documents/fighting_For_Breath1.pdf.2005
[7] OJ C 189, 26.7.1989, p 1-2
[8] OJ L 22. 25.I.2003, p.31-34
[9] Arnardóttir, Ragnheiður Harpa (2007). Physical Training and Testing in Patients with Chronic Obstructive Pulmonary Disease (COPD). http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-7632 (2007-05-18)
[10]Jaakkola MS, Piipari R, Jaakkola N, Jaakkola JJ. Environmental tobacco smoke and adult-onset asthma: a population-based incident case-control study. Am J Public Health. 2003 Dec;93(12):2055-60.)
[11]UK Department of Health 1998 Report of the Scientific Committee on Tobacco and Health. HMSO, London, p 31–32)
[12] Thomson NC. Smokers with asthma: what are the management options? Am J Respir Crit Care Med. 2007 Apr 15;175(8):749-50
Tomlinson JE, McMahon AD, Chaudhuri R, Thompson JM, Wood SF, Thomson NC. Efficacy of low and high dose inhaled corticosteroid in smokers versus non-smokers with mild asthma. Thorax. 2005 Apr;60(4):282-7